Part 53

Extension on the foot, and counter-extension on the leg, dislodged the parts by degrees from their accidental situations, while, by the process of conformation, the surgeon endeavoured to bring them into their natural ones. This was soon effected without much violence: the unfavourable appearances soon vanished; the pain ceased; an apparatus similar to the former one was applied, and kept wet with a strong solution of common salt, instead of the vegeto-mineral water.

In the evening, the pulse being full, and somewhat raised, a moderate blood-letting was deemed necessary. Next day, the apparatus was kept constantly moist, and some part of it which had become relaxed was tightened. The pulse continuing full, a low diet was prescribed.

Fifth day, the apparatus taken off; contact between the bones perfect: a yellowish tinge bespoke an incipient resolution of the echymosis: a slight swelling of the leg: vesications formed on the part: these are opened and a quantity of acrid water discharged from them. Sixth day, light nourishment allowed; a small excoriation of the heel, which is dressed with cerate spread on a linen rag. Seventh day, regimen less strict; no bad symptoms supervene. Eighth day, the excoriation enlarged; same dressing. Tenth day, the excoriation become fungous: caustic is applied to remove it.

Twenty-eighth day, the discharge from the leg decreased; from this time the dressings are renewed only every other day. Thirty-second day, the ulcer is cicatrized: no pains in the leg. Thirty-ninth day, fracture of the fibula firmly united: no deformity remaining; the apparatus is laid aside: the joint remains stiff: motions performed by the limb difficult at first, but become gradually more free. Forty-sixth day, symptoms of bile; gentle evacuants. Fifty-fourth day, the patient is discharged cured, except a slight impediment in walking, which exercise will soon remove.

12. To this example, I might add many others, where similar displacements, properly treated, terminated with equal success: no pain; no swelling; no inflammation; and therefore, of course, no mortification. Yet these are occurrences of which authors speak, as if they were the usual consequences of such luxations, where, to a violent injury done to the soft parts, is added a fracture near to, or even communicating with, a joint. The erroneous opinions of the ancients and most of the moderns, respecting the dangers arising from such vicinity or communication, have contributed not a little to their unfavourable prognosis in the cases under consideration. Should the patient survive the disease, his inevitable lot, according to them, must be, a complete anchylosis of the leg with the foot. But, the preceding cases fully prove, that this apprehension is unfounded. A considerable time is doubtless necessary, for the recovery of motion, on account of the distension and rupture of the ligaments, the long continued inactivity of the parts, and the swelling which they have undergone. But this recovery can always be effected by means of exercise, gentle at first, increased afterwards, and regulated according to the principles so frequently laid down in the course of this work. Much more to be relied on is such exercise, than the long catalogue of discutient means, such as pumping of water on the parts, alkaline baths, mineral waters, and all other external applications, so often extolled as efficacious, and so often found entirely useless.

§ III.

LUXATION OF THE FOOT, COMPLICATED BY A SEPARATION OF THE BONES OF THE LEG, AT THEIR LOWER END.

CASE III. (The following case was reported by Thevenot). I. Joseph Schneider, an ebonist, aged thirty-six, as he was walking in haste, on the 23d of March, 1792, fell forward, his foot being forced backward and outward. He experienced at the instant severe pains in the joint: he was unable to rise, and was therefore carried home, where a surgeon, after making a slight extension, applied a roller on the limb, and did nothing further. The patient experienced no relief. The pains increased; a swelling supervened; convulsive motions began to occur; and the patient was brought to the Hotel-Dieu, six days after the accident.

From the deformity of the foot, Desault immediately discovered that it was luxated. Its point was directed outwards, while its sole was turned in the same direction: beneath the malleolus internus, which was too prominent, was a tumour formed by the astragulus. The crepitation of the bones which was easily heard, the preternatural distance between the tibia and the fibula, the mobility of this latter bone, and the absence of the signs of a fracture, plainly showed that a separation of the two bones of the leg had taken place.

A reduction was immediately effected by means of extension and counter-extension, and was announced when it took place by a report distinctly heard. It was then retained by a bandage, calculated to answer a twofold purpose; 1st, to approximate, and keep together, the two bones of the leg: 2dly, to secure the contact and immobility of the bones of the foot.

Blood-letting was prescribed: an anodyne mixture administered; low diet; in the night severe pains were felt; next day, they were increased; on dressing the limb, nothing amiss discovered; all the parts in perfect contact: no vestige of separation between the tibia and the fibula: a new apparatus applied; and kept constantly moist. Third day, the patient better: fifth day, the fibula a little separated from the tibia: the circular bandage drawn tighter to reduce it to its place again. Tenth day, every thing in its natural state: no pains: swelling gone. Fifteenth day, a simple roller substituted in place of the bandage for a fracture of the leg. Nineteenth day, the patient began to walk, with the assistance of a stick: twenty-third day, walks easily: twenty-eighth day, is dismissed perfectly cured, and nearly free in all his motions.

13. The separation of the bones of the leg, at their lower end, does not constitute a very serious complication of luxations of the foot, although the contrary is asserted by several authors. Desault met with this accident several times in the course of his practice, but never saw it terminate otherwise than favourably. But here, as in all other cases, the most minute attention is necessary to ensure success, the want of which is more frequently owing to the negligence of the surgeon, than to the deficiencies of the art. The bandage employed after reduction ought to act principally from without inwards, and in a direction perpendicular to the axis of the lower part of the leg, in order to approximate the two bones. It will be of some service, in this respect, to place on each bone a compress, which, projecting more than the rest of the circumference of the limb, will be more compressed, and on that account, contribute to the end in view.

§ IV.

LUXATION OF THE FOOT, ACCOMPANIED BY A DISPLACEMENT OF THE ASTRAGULUS AT ITS ARTICULATION WITH THE OS SCAPHOIDE.

14. Petit never met with more than two instances of that displacement of the astragulus, now under consideration. His general prognosis on the subject is more favourable than that respecting other luxations of the foot, with which he never saw the present luxation of the astragulus complicated, as occurred in the following cases. Had such complex cases fallen under his notice, there can be little doubt, but he would have declared amputation to be the only recourse of art on the occasion.

But the experience of Desault demonstrates to us here, as well as in the preceding cases, the great extent to which we ought to carry our confidence in the powers of nature, when skilfully guided by the hand of art. The following case was communicated to me by Leveille.

CASE IV. John Baptist Landrin, a postilion, aged thirty-six, was brought to the Hotel-Dieu, on the 19th of February, 1791.

On the morning of the same day, a horse on which he was mounted having fallen, his foot was caught under the belly of the animal. As soon as he was disencumbered of the vast weight, he endeavoured to rise, but in vain. The pains which he experienced in his foot were extreme. He was carried home, where some surgeons, having ascertained that his foot was luxated, but being unable to reduce it, sent him to the Hotel-Dieu.

Desault on examining him, found the bones of his foot to be situated as follows. The internal part of the os calcis corresponded to the lower extremity of the tibia: the back of the foot was directed outwards, and its external edge downwards: under the skin and in front of the tibia was the astragulus, resting on the scaphoide and first of the cuneiform bones, where it formed a considerable projection: on the back of the leg, the fibula corresponded to the tendo Achillis. The pains had been inconceivably great from the moment of the accident.

Imboldened by numerous instances of success in similar cases, Desault, notwithstanding the extent of the disease, attempted the reduction. One assistant took hold of the superior part of the leg to make counter-extension, and another, for the purpose of extension, grasped the metatarsus with one hand, and the heel with the other. While these were pulling in different directions, the surgeon applying his thumb on the astragulus, endeavoured to force it into its place. His efforts were ineffectual: the opening through the capsule of the astragulus being too narrow, would not suffer it to pass. Desault perceiving this, cut through the integuments which covered the bone, and having laid bare the capsule and the ligaments which strengthen it, made an incision into them of a sufficient extent, taking care to avoid the tendon of the tibialis anticus, which was brought into view. The openings being thus enlarged, admitted of an easy reduction, and all the parts resumed, without difficulty, their natural situation.

The reduction being effected, the wound was closed, and covered with some lint. A square compress was then placed on the back of the foot, while a long one was applied to its sole, and the whole secured by an apparatus similar to that described in the preceding case. The patient was confined to a very strict diet, and ordered to use diluting drinks.

Next day, a slight bilious diathesis; an emetic in solution given; apparatus renewed. Fourth day, an abscess on the malleolus externus opened; a copious discharge of pus. Eighth day, the parts in perfect contact; a favourable discharge from the wounds; dressings applied twice a day. Fifteenth day, a general œdema; aperient ptisans ordered. Twentieth day, the œdema gone: a bilious diathesis returned: in consequence of this, the wounds became pale: another emetic given. Twenty-seventh day, a very painful excoriation occurred on the heel: care taken not to let the foot rest on that part, as the sore appeared to be the effect of compression. Thirtieth day, the wounds in a favourable way: all the bones in exact contact. Fortieth day, apparatus laid aside, and a simple roller substituted in its place: wounds already cicatrizing. Fiftieth day, the limb put in gentle motion, which is gradually increased every day. Same dressing continued till the eightieth day: wounds not yet cicatrized. Hundred and twenty-seventh day, a considerable swelling around the joint: a splinter made its way out, and was followed in a few days by several more. In the fifth month an abscess formed on the heel, from which, when opened, another splinter escaped. In the mean time, the patient left the Hotel-Dieu. During his absence more splinters were discharged. Returning about a year afterwards with a small ulcer, he was dismissed again in a short time, perfectly cured, except a slight stiffness of the joint.

15. The reduction of this luxation of the foot presents a difficulty worthy of the attention of practitioners, as well on account of its own nature, as in consideration of the process which was employed on the occasion: I allude to the narrowness of the opening in the capsule. I mentioned, on a former occasion, the obstacles sometimes created by this circumstance to the reduction of luxations of the os humeri and the os femoris. It was impracticable in the present to enlarge the opening in the capsule, as could be done in those cases, by moving the head of the bone in all directions; because the bone was too small to afford any purchase to the surgeon. The only resource was, the use of the knife; and the operation was the more easily performed, on account of the capsule being situated immediately beneath the integuments, from which circumstance it could be the more speedily brought into view.

16. The apprehension of mischief resulting from the admission of air to the articulating surfaces, would no doubt, in this case, have restrained most practitioners: but, even supposing this apprehension to be well founded, ought it to deter the surgeon from adopting the only possible mean of effecting a reduction, and of thus putting an end to the alarming state of things arising from the displacement of the bones? Desault proved in numerous instances, that the apprehensions of authors respecting such cases have been greatly exaggerated, and that it is practicable to cure wounds that penetrate into the cavities of joints, in the same manner as if they were simple wounds, and with but very little more danger to the patient. Yet it would seem, that the tediousness of the cure and the exfoliation of the bones, arose, in the present case, from the opening made into the joint, and perhaps also, in part, from the disposition and habit of the patient. Finally, in those alarming injuries of the joints, unconnected with external wounds, where practitioners have looked to no resource but that of amputation, Desault has, in a short time, and without any dangerous occurrence, restored to the subjects the free use of their limbs. The following case, drawn up by Plaignault, is a proof of this.

CASE V. Pierre Phipe, aged twenty-four, fell, on the 20th of February, 1788, from an elevation of more than twenty feet: lighting on his foot, he turned it outwards, sunk instantly to the ground, and was unable to rise again. He was carried home, and from thence to the Hotel-Dieu.

Desault examining him on his arrival, discovered a luxation of the foot outwards, and of the astragulus forward and upward: the patient’s sufferings were great. Convinced that the most effectual method to relieve these was to reduce the luxation, the surgeon undertook it immediately, pushed the astragulus into its place without difficulty, and with a report which was heard by every one present, while the bones of the foot were brought into their proper situation by means of extension. In an instant the pains vanished and the motions of the foot became easy. The necessary apparatus was applied. The activity of the pulse called for blood-letting, which was immediately performed. A low diet was prescribed.

On the two following days blood-letting was repeated, both on account of the active state of the pulse, and of a considerable swelling which took place in the joint. The apparatus was kept constantly wet with vegeto-mineral water. Eighth day, somewhat better: echymosis gone. Fifteenth day, the apparatus laid aside. From this time the foot was gently moved every day. Eighteenth day, the patient able to stand on the affected foot without pain. Twenty-sixth day, walks with the assistance of a staff. Thirty-ninth, walks without limping, and enjoys all the motions of the foot. Discharged.

§ V.